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MTA and calcium hydroxide for pulp capping

Alexandra Mussolino de QueirozI; Sada AssedI; Mario Roberto


LeonardoII; Paulo Nelson-FilhoI; Léa Assed Bezerra da SilvaI

I
Professor at Department of Pediatric Dentistry, Ribeirão Preto Dental
School, University of São Paulo, Brazil
II
Professor at Department of Restorative Dentistry, Araraquara Dental
School, State University of São Paulo; Visitant Professor of the
Ribeirão Preto Dental School, University of São Paulo, Brazil

ABSTRACT

This study evaluated the biocompatibility of mineral trioxide


aggregate (MTA) after direct capping of exposed pulp tissue in dog's
teeth. Class I cavities were prepared in 26 teeth from 3 adult dogs.
MTA was applied over the exposed pulp in 13 teeth and paste of
calcium hydroxide plus distilled water (control) was applied in the
remaining 13 teeth. After 90 days, the animals were killed; the
maxilla and mandible were dissected and sectioned to obtain
individual roots. The samples were processed histologically. The pulp
and periapical response observed with the use of MTA was similar to
that of calcium hydroxide paste. In all specimens, there was a dentin
bridge obliterating the exposure, an intact odontoblastic layer, no
inflammatory cells, normal connective pulp tissue, normal apical and
periapical regions and no bone tissue changes. Similar to calcium
hydroxide, MTA presented excellent response when used for direct
pulp capping.

Uniterms: Dental pulp capping; Calcium hydroxide; Mineral trioxide


aggregate.

RESUMO

O objetivo deste trabalho foi avaliar a biocompatibilidade do agregado


de trióxido mineral (MTA), após proteção pulpar direta em dentes de
cães. Foram preparadas cavidades de Classe I, em 26 dentes de 3
cães adultos. O MTA foi aplicado sobre 13 dentes e a pasta de
hidróxido de cálcio (grupo controle) foi aplicada sobre os 13 dentes
remanescentes. Após 90 dias, os animais foram mortos, a maxila e a
mandíbula foram dissecadas e os dentes foram seccionados para
obtenção de raízes individualizadas. Os espécimes foram processados
histologicamente. A resposta do tecido pulpar e periapical foi
semelhante para o MTA e o hidróxido de cálcio. Em todos os
espécimes havia ponte de dentina obliterando o local da exposição
pulpar, camada odontoblástica íntegra, ausência de células
inflamatórias, tecido pulpar normal, e ausência de alterações na
região periapical e óssea. Da mesma maneira que o hidróxido de
cálcio, o MTA apresentou excelente biocompatibilidade quando usado
para proteção pulpar direta.
Unitermos: Capeamento da polpa dentária; Hidróxido de cálcio;
Agregado de trióxido mineral.

INTRODUCTION

Direct pulp capping is a dental procedure in which the exposed pulp is


covered with a protection material, minimizing additional injury and
allowing exposed tissue to heal7,28. This treatment is indicated when
the pulp is accidentally exposed during cavity preparation23 or by
trauma and should be done immediately, or at least 24h after its
occurrence2.

Calcium hydroxide continues to be the most accepted material for


pulp capping. When calcium hydroxide is placed in contact with the
pulp tissue, it preserves vitality, with no inflammatory response,
stimulating the formation of a mineralized tissue barrier7. Although
treatment with calcium hydroxide has been successful, in the last
decade other materials have been tested as pulp protectors in vivo
and in vitro, such as adhesive systems4 and mineral trioxide
aggregate1,21.

Mineral trioxide aggregate (MTA) was developed at the University of


Loma Linda (USA) to seal communications between the root canal
system and the external tooth surface at all levels27, and recently
indicated in pulp treatment as direct pulp capping1,21.

The following properties of MTA have been reported:


biocompatibility13,16,24, great sealing capacity26,27, antibacterial
effects25, no mutagenic potential14, low cytotoxicity13, no change in
cytomorphology of osteoblastic cells15, stimulation of formation of
mineralized tissue1,12, coverage by cementum12, aid in periodontal
ligament regeneration22 and lead to biological response in osteoblastic
cells16,18.

The aim of this study was to evaluate histopathologically the response


of the pulp tissue and the periapical region when applying MTA
directly over the exposed pulp in dog's teeth, using calcium hydroxide
plus distilled water as a negative control.

MATERIAL AND METHODS

The second and third maxillary premolars and second, third and
fourth mandibular premolars of three mongrel dogs (age: 12-18
months old; weight: 8-10 kg), totaling 26 teeth were selected for
treatment.

The animals were anesthetized intravenously with 3% sodium


thiopental (30 mg/kg body weight; Thionembutal, Abbot Laboratories,
São Paulo, SP, Brazil). Standardized periapical radiographs were
taken with a Heliodent RX machine (Siemens, Erlanger, Germany)
with 60 kVp, 10 mA and 0.4 s exposure. Ultraspeed periapical film
(Eastman Kodak Corp., Rochester, NY, USA) was used and the
radiographs were processed by the time/temperature method.

After prophylaxis, the dental area was isolated with a rubber dam and
the operative field was disinfected with 2.0% chlorhexidine gluconate.
Two distinct class I cavities were prepared on the occlusal portion,
one mesial and one distal, with a high-speed #1015 round diamond
bur (KG Sorensen, Ind. Com., São Paulo, SP, Brazil) under copious
water spray, creating standardized pulp exposures (1-mm diameter).
Intermittent movements were performed during cavity preparation to
avoid the generation of excessive heat. After pulp exposure, the
cavities were then irrigated with saline (0.9% sodium chlorite,
Glicolabor Ind. Farm. Ltda, São Paulo, SP, Brazil) to control
hemorrhage and remove debris.

Because all variables should be tested in the same animal and in the
different quadrants, each hemiarch was submitted in an alternate
manner to the experimental protocols.

The pulp exposure was dried with sterile cotton pellets. Group I (13
teeth): the exposed pulp tissue was covered with MTA powder mixed
with distilled water at a 3:1 powder:water ratio (MTA, Dentsply, Tulsa
Dental, Tulsa, OK, RJ, USA), according to the manufacturer's
instructions. After initial setting and removal of excess from the cavity
walls, an adhesive system (Prompt L-Pop, Espe Dental AG, Germany)
was applied with microbrushs for 15 s. Gentle air jets were applied
until a thin, shiny, and homogeneous layer was obtained. The
adhesive was cured for 10s (Ultralux Eletronic, Dabi Atlante, Ribeirão
Preto, SP, Brazil).

Group II (13 teeth): the exposed pulp tissue was covered with a
calcium hydroxide paste (0.5 g of calcium hydroxide p.a. Merck,
Germany plus 0.5 mL of distilled water) mixed at the time of the
procedure. A calcium hydroxide cement (Dycal, Dentsply Ind. Com.
Ltda., Petrópolis, RJ, Brazil) was then applied, followed by application
of Prompt L-Pop adhesive system.

The cavities of both groups were restored with a microhybrid light-


activated resin composite (Z-100; B2 color; 3M do Brasil Ltda.,
Sumaré, SP, Brazil), inserted using the incremental placement
technique. Each increment was approximately 1mm thick and was
light cured for 40 seconds. The light curing unit was 450mW/cm2. For
adequate cure, the light-curing unit was monitored throughout the
study with a radiometer.

Ninety days after the surgical procedure, all teeth were radiographed
in a standard manner, and the animals were killed by anesthetic
overdose. The maxilla and mandible were dissected and sectioned to
obtain individual roots, and the dentin bridging was evaluated
separately for each cavity preparation. Serial 6-µm wide longitudinal
sections were stained with hematoxylin and eosin, Mallory's
Trichrome and Brown and Brenn.
Histopathological analysis was subjectively performed using a light
microscope. The following parameters were analyzed: presence or
absence of dentin bridge, presence or absence of pulp tissue changes,
intensity of the inflammatory infiltrate (absent, mild, moderate or
severe), type of inflammatory infiltrate (acute, chronic or mixed),
periodontal ligament thickness (normal, slightly, moderately or
intensely increased), presence or absence of resorption of mineralized
tissues (dentin, cementum or alveolar bone) and changes at the
periapical region.

The results were submitted to statistical analysis using the Mann-


Whitney nonparametric test with a equal to 0.05. The computer
package used was GMC 8.1
(http://www.forp.usp.br/restauradora/gmc/gmc.html).

RESULTS

After ninety days, the results were similar (p>0.01) in the 13 pulps
treated with MTA (Figures 1, 2 and 3) and in the 13 pulps treated
with calcium hydroxide (Figures 4, 5 and 6). There was a compact,
thick dentin bridge totally obliterating the pulp exposure, and a layer
of normal odontoblasts under the dentin bridge. The connective pulp
tissue was intact in all specimens with fibroblasts and a moderate
quantity of collagen. There was no inflammation and the connective
tissue was normal. The periapical and apical regions were normal with
cementoblasts in the cementum surface. The alveolar bone had
osteoblasts in the surface and no signs of resorption. The periodontal
ligament, composed of dense vascularized connective tissue, was of
normal thickness with no inflammation. Bacteria were not observed.

DISCUSSION

In the present study, 100% of the specimens capped with MTA and
calcium hydroxide paste presented a compact thick dentine bridge,
normal odontoblastic layer, connective pulp tissue and apical and
periapical regions with no inflammatory response, with no bone,
cementum or dentin resorption.

According to Zander29 and Hess8, the main indicator of success in


direct pulp capping or pulpotomies is the formation of dentin bridges.
Specific literature has shown that MTA stimulates the formation of
mineralized tissue1,9 and recent studies1,5,9,21 have applied MTA directly
to the exposed pulp tissue in direct capping or pulpotomies, forming
dentin bridges and showing no inflammatory response. This was
confirmed in the present study, with formation of a thick compact
dentin bridge obliterating the exposed site in 100% of the cases after
90 days of MTA pulp capping.

Faraco Júnior and Holland (2001), comparing the response of the pulp
of dogs to capping with MTA or a calcium hydroxide cement, observed
that MTA exhibited better results than the calcium hydroxide cement5.
MTA can induce biological responses in osteoblastic cells due to
adhesion30, increasing cytokines16,18 and osteocalcine production16.
Osteocalcine is the most found non-collagenic protein characteristic of
osteoblast synthesis, and can be used as an indicator of matrix
production. Thus, MTA presents a biologically active substrate for
bone cells and stimulates the production of interleukines15. However,
according to Moretton, et al.19, MTA is not osteoinductive (does not
induce the differentiation of cells that produce bone tissue in tissues
where bone is not present, such as connective tissue) but is only
osteoconductive (stimulates the production of mineralized tissue in
areas where this tissue is normally present).

The formation of dentin adjacent to the MTA occurs due to its sealing
ability, which prevents microleakage, to its biocompatibility, alkalinity,
or due to other properties such as the capacity to stimulate cytokine
release by the bone cells21.

When analyzing the action of MTA after implantation of dentin tubes


filled with MTA or calcium hydroxide and distilled water paste in the
subcutaneous connective tissue of rats to observe the action of MTA
and calcium hydroxide on the dentin walls, Holland, et al.11 found
large and birefringent granulation deposits near the tube opening and
inside the dentinal tubules. These granulations are calcite crystals
originated from the reaction of calcium hydroxide with tissue carbon
dioxide, which allied to fibronectin, are the precursors of mineralized
tissue barrier. The similar results found for calcium hydroxide and
MTA, which does not have calcium hydroxide in its composition, occur
because MTA contains calcium oxide, which reacts with tissue fluids to
form calcium hydroxide. Holland, et al.10 observed that when MTA is
in contact with water, calcium oxide forms calcium hydroxide, which
reacts with tissue carbon dioxide producing calcite crystals. The tissue
in contact with these crystals forms an extracellular fibronectin mesh.
Thus, they conclude that the MTA mechanism of action is similar to
that of calcium hydroxide.

The present study did not show bacteria in any specimen of either
group, which is probably due to the fact that there was no marginal
leakage and that the materials used had antibacterial activity. The pH
of MTA immediately after manipulation with distilled and deionized
water is 10.2, increasing to 12.5 after 3h and then remaining
constant. Similar to calcium hydroxide, the high pH of MTA is
responsible for its antibacterial activity25.

It should be emphasized that the favorable results found when


applying calcium hydroxide paste over the exposed pulp tissue are
due to its biocompatibility20, antibacterial activity6,17 and stimulation of
mineralized tissue deposition3, which stimulate the healing process.

We believe that the excellent results found with MTA and calcium
hydroxide allow its recommendation for direct pulp capping. However,
MTA is expensive and research results are related to short-time
periods. On the other hand, calcium hydroxide has a low cost, is
easily found and has been presenting excellent clinical, radiographic
and histopathologic results over the last 80 years.
CONCLUSION

Mineral trioxide aggregate presented similar response to calcium


hydroxide in the pulp tissue and periapical region when used for direct
pulp capping.

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